15. Access to care
Matter for discussion submitted by the RCN Older People's Forum
That this meeting of RCN Congress considers how to achieve equitable access to health care services for older people who live in care homes
Progress report
Submitted by: Public Health Forum
Council lead and committee assigned: Gill Cort and Jane Bovey (until October 2011), Ian Norris and Stuart Young (from October 2011), Nursing Practice and Policy Committee
Committee decision: Integrate project into ongoing work stream
Members involved: Members extensively consulted on the Government white paper
Final summary update at May 2012
Issues surrounding the health services available to older people in care homes were discussed at Congress last year with inconsistent care and cost cutting cited as areas of concern.
Since Congress, the RCN has worked with the British Geriatrics Society to produce the report Quest for quality. The report describes current NHS support for care homes, looking at unmet needs, unacceptable variations and often poor quality of care provided, covering what could be done to make improvements. RCN member Hazel Heath, Chair of the RCN Older People’s Forum, worked on the report.
In March 2012, the RCN published Persistent challenges to providing quality care, which addressed the worrying trends related to the quality of care in care homes. The report analyses issues such as inadequate funding and staff levels; appropriate skill mix of staff, high turnover of staff; low levels of morale; and lack of equipment in homes. The RCN makes recommendations for action to address these issues and is also working with representatives from the independent sector to explore how the RCN can better support members working in care homes.
At Congress 2012 the RCN Older People’s Forum is holding an event which will explore the key issues currently impacting on care homes in the UK, and discuss how the role of registered nurses in care homes is evolving. A discussion and guidance document titled Older people in care homes: sex, sexuality and intimate relationships will also be launched.
At the Congress event RCN members who work in care homes will be able to discuss with the RCN Older People’s Forum committee how they would like the RCN to support them in their work.
Update at November 2011
Joint work with the British Geriatrics Society (BGS) has resulted in the report Quest for quality, published by the British Geriatrics Society in June 2011 and launched at the House of Lords.
The Quest for quality report describes current NHS support for care homes, looking at unmet needs, unacceptable variations and often poor quality of care provided. It covers what could be done and calls for national action by government and local action by NHS commissioners, planners and clinical services to improve the quality of NHS support to care homes, highlighting the need to build joint professional leadership from the health, social, and care home sectors, statutory regulators and patient advocacy groups to find solutions.
The launch of the report was attended by Chair of the RCN Older People’s Forum Hazel Heath, who has been an active contributor to the Joint working party inquiry which produced the report, undertaking qualitative research with the BGS around the quality of healthcare support for older people in care homes.
RCN Adviser for Older People Nicky Hayes also attended the launch, and Hazel Heath and Nicky Hayes will continue to link with the British Geriatrics Society on next stages on Quest for quality. There is no update at this point of time from the BGS on when the next stage of work will start.
In September the RCN hosted an event at its London headquarters which explored how the RCN may work further with the independent sector. The event was held in conjunction with the National Care Forum, Registered Nursing Home Association and English Community Care Association
The RCN Older People’s forum has developed a proposal for a congress fringe event for 2012 on working with the Independent Sector.
Debate report
Older People’s Forum member Hazel Heath proposed this matter for discussion. She started by saying that with the urgency of other issues this week, it’s important that we hear the voices of those that are quiet; older people in care homes. She said that although there is good care, access is patchy, varies with postcode and isn’t a priority.
Hazel continued by saying that many care home residents are excluded from NHS services and that there was evidence collection in process that would show the “patchy” access to care.
Jean Richards, Wrexham and Flintshire branch, said that in Wales they consider themselves to be doing well in this area, but that the whole of the UK should have equitable access.
Francis Lavery, Older People’s Forum, said that Northern Ireland was doing relatively well in improving care for older people, but despite this area being a priority, the “cuts will bite hard.”
“This shouldn’t even be an issue,” said Gary Roberts of the Older People’s Forum, adding that all older people deserve equal access to care, whatever the health care setting or situation.
Many shared the view that this was a complex issue with no easy solution but that everyone has a fundamental right to access the same level of care.
Soline Jerram of East Berkshire and Broadmoor branch said that core care and specialist care in this area needed to be clarified, while Catrina Forsyth said that “all areas should have their own Darzi practices” and that it was a commissioning matter.
Hazel Heath closed the discussion by saying that proactive health care not only gives older people greater quality of life, it also saves money. She urged Congress to use their influence to ensure older people, “the generation that built the NHS,” aren’t forgotten.
Background
Services provided by care homes in the UK are required to meet national minimum standards, published by the Secretary of State for Health (Department of Health, 2003), which require providers to ensure that service users’ entitlements to NHS services are upheld in accordance with guidance and legislation.
Residents are also entitled to be assessed for eligibility for both NHS funded continuing health care and NHS funded nursing care under the National framework for NHS continuing healthcare in England (revised 2009) and equivalent guidance in each UK country. However, neither this nor the Care Standards Act cover the issue of eligibility or the provision of specific health care services.
By law GPs must provide general medical services to people who live in any setting, if they are registered patients or temporary residents. The NHS (General Medical Services Contracts) Regulations 2004 sets out the required essential services to people who are ill, terminally ill or have chronic diseases. But there is no requirement for GPs to provide enhanced levels of support for people with complex needs who are living in care homes. Enhanced services that fall outside the general medical contract may be negotiated locally by commissioners, but there is widespread variation between commissioning bodies. Some care homes may pay privately for therapy sessions or for enhanced medical services, but pass on these costs to their residents. For residents who are receiving state assistance with their fees, or who are self-funding in homes that do not make arrangements privately, these additional services may not be an option.
The provision of non-medical services is also locally determined. Some care homes are developing new models of care, providing intermediate care and rehabilitation services that are commissioned by NHS/local authorities, but there is considerable variation in this across commissioning services.
In Scotland the Scottish Government, NHS and the Convention of Scottish Local Authorities are embarking on a major programme to reshape care and support services to meet policy objectives in a sustainable way. The Reshaping care for older people agenda aims to give care homes a greater role in rehabilitation and short term care, and develop new models of care to provide homes for residents with particular requirements such as dementia care, or palliative and end-of-life care.
RCN members in Northern Ireland report that people in care homes are generally able to access specialist services without having to pay for them. The deployment by trusts of clinical nurse facilitators and specialist tissue viability services is seen as key to this process, but members have reported inconsistencies in the provision of support for people with dementia living in general care settings.
In England, the commissioning plans of GP consortia and shadow NHS commissioning boards – due to be completed in 2011/2013 - will include the commissioning arrangements for health care for care home residents. Meanwhile, in Wales the Government’s stated intention is to move the focus of health care from hospitals and into people’s homes and the community is an important issue.
References and further reading
Alzheimer’s Society (2008) Home from home: a report highlighting the opportunity for improving standards of dementia care in care homes, London: Alzheimer’s Society. Available at: www.alzheimers.org.uk/site/scripts/download_info.php?fileID=270
(accessed 8/2/11) (Web).
British Geriatrics Society (2011) Health care in care homes, London: BGS.
(Research being undertaken by BGS and Royal Colleges to be launched in April 2011)
Department of Health (2003) Care homes for older people: national minimum standards and the Care Homes regulations 2001 (3rd revised edition), London: Stationery Office. Available at: www.dh.gov.uk (accessed 8/2/11) (Web).
Joint Improvement Team (2011) Reshaping care for older people, Edinburgh: JIT. Available at: www.jitscotland.org.uk/action-areas/reshaping-care-for-older-people/ (accessed 8/2/11) (Web).